Breast cancer patients rest in peace

If you had cancer, how good would a treatment have to be, how much would it have to help, for you to use it? How about if it gave you a 5% better chance of cure? A 10% chance? How about a 20% chance to be beat the disease using a treatment without side effects that is free? “Sign me up,” you say? Nonetheless, only 8% of breast cancer patients use a therapy that has a 25% likelihood of curing them of the dread disease? Ridiculous? Yes, but true.

What is this magic intervention estimated by the World Health Organization to reduce the risk of getting breast cancer by 20 – 40% and decrease the risk of cancer’s return by 26 – 40%? That means at least one in four breast cancer patients who would otherwise die, could survive. The complex, high technology, state-of-the art miracle is: exercise.

There is no debate that exercise decreases the occurrence of multiple cancers (breast, colon, prostate…), increases cure rates and markedly improves quality of life. The incredible thing is; NO ONE DOES IT!

In the Journal, Cancer Epidemiology Biomarkers and Prevention (not high on your reading list, I suspect), Caitlin Mason et al, studied physical activity levels in 631 women, ages 18-64, after treatment for breast cancer. In the first 2 years after diagnosis, 39.5% exercised. A fair start. However, regular exercise fell steadily until by 10 years only one in five exercised at all and only 8% got the recommended minimum of physical activity over the entire period. Reverse those numbers; nine out of ten women reject a treatment modality which has a 25% of saving them.

How good is 25%? Would you not look crossing the street, one in four times? Would you pull the trigger of a gun pointed between your eyes, if it had a one in four chance of blowing your head off? Do you understand that adjuvant chemotherapy, that is medical treatment given after breast surgery to prevent relapse, often improves your chance of life by only 10%? Chemo gives you a one in ten improved chance to live, while exercise better than one in four? A no brainer.

How does exercise work? Scientists are not sure. Likely, it is more than simply weight. It probably relates to better glucose, insulin, estrogen and other hormone levels, as well as benefits to the immune system. Cardiovascular health supports healing and defense, as well as the ability to tolerate needed medical interventions. Perhaps people that are out exercising are spending less time in smoke or radon filled rooms. Whatever the biology, those that exercise not only have better general fitness, but live longer to enjoy it.

We all have heard the excuses; Do not have the time, its too hot or too cold, I’m am not in the habit of exercising, my knee or my back are bothering me, etc. All “valid” reasons not to move. The bad news is that your body does not care! Your immune system, cardiovascular system, neuroendocrine system and every other part that is trying to protect you from deadly disease, does not know that you have a deadline, that it is raining, that you hate to sweat or that you are a klutz. Your body only knows that if you do not battle against the disease, then it does not need too either. This is not a benign lifestyle change such as whether you will read a book or watch TV, paint the bathroom blue or pink, or eat apples verses oranges. This a much more basic decision; will I live or will I die?

How much is enough? We should get some sort of regular exercise at least 30 minutes (45 is better), five (5) times a week. That is less than 2% of our time. The type of exertion does not matter. Walk, jog, bike, swim, yoga, dance, garden, mow the lawn, tennis or sex (just what the doctor ordered…”honey, its anti-cancer time”). That means trading one week a year of exercise “therapy”, for years of cancer free life.

Therefore, if you have ever had cancer, if you are concerned that you might someday get cancer, if you know someone who met someone that is concerned that they might ever have cancer, it is time to get off your butt and start your war against the disease. There may be no other intervention you can do which has a better chance of protecting you. Stay on the couch and you may find it truly is a rest in peace.

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45 Comments

Mary

July 27, 2013 at 6:39 AM

And some of us DO exercise even as doctors tell us NOT to do so. I'm hastening my death according to some, but it is one of the few ways left where I can relieve pain with out popping yet another pill - both physical and psychological. And it is hard to believe that something with so many benefits will truly be the thing that takes me out. What irony if it proves to be true - a lifetime of exercise and I should have hit the COUCH instead of the gym/pool/road.
Time will tell which was right . . .

Because anything that stresses my heart puts me at great risk of SCA according to the experts. I subscribe to the theory that, yes, it is possible of dropping dead while exercising BUT in any exercise event that I DON'T drop dead, I am strengthening various muscles that would keep me alive should the body feel like dropping dead in future. A veritable tight rope to balance . . .

A tough balance ... SCA (sudden cardiac arrest), verses letting your body weaken. Both really frightening. It is an example of where the balance of the patient - physician relationship and good communication is so critical to stay on, what is at least perceived, as a narrow path.
Keep it up,
jcs

Yup, exercised all the time before I was diagnosed with breast cancer, continued to walk regularly during breast cancer treatment, and went back full steam ahead following treatment and surgery. I was one of the very few (only one?) dressed in my tennis outfit while I got my Herceptin. Of course you hear all the time, "That person was so healthy....exercised, ate right, didn't smoke..." I call it the crappy luck factor. Anyway, if nothing else, I feel great and strong. And I hope for the best in the future.

I believe that the CLF (crappy luck factor) requires more study. Any thoughts you have on this subject would be welcome. In the mean time, keep it up, I have no doubt you are making a big difference. jcs

I have done some kind of exercise most of my life. I had breast cancer 23 yrs. ago and it came back late last year. Iwent 23 years cancer free thanks to Dr. Salwitz and his treatments. I don't know if exercise helps prevent recurrence but I couldn't move today without it. I have R.A. so it helps to do some moderate exercise . Exercise has more than physical benefits. It also helps one cope mentally and sometimes spiritually.

The mental and spiritual side of exercise should be enough to make us get up and move. Somehow as fresh air moves in, the muddle of modern life, moves out. I have no doubht that those 23 years were, in major way, earned in sweat (although I do appreciate taking credit for a few days or weeks ... perhaps a particularly sunny day, at the Jersey shore).
jcs

I started running years ago after I broke my leg ice skating...to build up my calf muscle. I stopped for years..then..I love the exhilaration of weight lifting..really running, sprinting..feels so good! I hope even at 63..I can manage a bit at a some point..if possible.

Wonderful post, Dr. S! And this wisdom is not limited to oncology - as cardiologist Dr. John Mandrola likes to advise heart patients:
"You only have to exercise on the days you plan to eat!"
That's why it's so troubling to read Mary's comment that seems as if somebody has warned her that exercise can induce SCA. Aside from recent studies on vigorous exercise in elite athletes, I've been unable to find evidence-based guidelines linking moderate daily exercise to increased risk of SCA in non-athletes. Just the opposite, in fact: the more you exercise regularly, the stronger your heart becomes. University of Alberta researchers suggest, for example, that heart attack survivors like me should be starting our Cardiac Rehabilitation exercise programs ONE WEEK post-cardiac event (instead of standard three months were were recommended for me).
And this Brigham & Women's study published in NEJM reported: "Habitual vigorous exercise diminishes the risk of sudden death during vigorous exertion": http://www.ncbi.nlm.nih.gov/pubmed/11070099
PS: Happy to report that we did a brisk 90 minute pre-breakfast walk this morning! :-)

Ahhh, Carolyn, they really don't know for sure but are concerned with the exercise induced angina that then goes full blown vasospasm and major constriction. It is a new concern as my condition proceeds along its path. Originally it was "exercise as much as you can". Now it is "max HR, min HR, max duration, time of day, nitro loading, etc etc" Chief of Cardiology just this week admonished me TO DO LESS to live longer - and he is a marathoner - his words "I don't want you dropping dead on me." I think the vigorous exercise research is not as applicable to vasospasm pts but I sure wish it was!

I was a runner, swimmer and cyclist at the time of my cancer diagnosis many years ago, and returned to all within 2 months after radical head and neck surgery, even during radiation and chemo, which surprised those treating me. Life affirmation, I suppose, and stress relief, certainly. After a car accident due to exceptional vulnerability to injury (see radical surgery) an orthopedist finally convinced me to drop running and concentrate on swimming. The days I exercise (swim, brisk walk, cycle or trail hike) I feel so much better in every way that it has become its own reward. In the last 12 years I've had 16 surgeries of various sorts (see radiation and radical surgery), many with casts and other immobilizers, so finding the right way to be active has been a challenge, and for periods I just had to accept that another form of healing took precedence. While I have a cardiac condition, AHCM, so far it seems that my heart is doing its job, and my cardiologist and I both think I should keep doing as much as I can. Mindfully, of course. Chemo-related lung damage seems to hold me back more than my heart.

I survive a rare adnexal carcinoma that began where my neck meets my head and metastasized to neck lymph during many confidant misdiagnoses. Very radical surgery (eye-popping for those who can recognize it) also severed spinal accessory nerve, but I think the issues in moving forward are common to many.

Thank you for your reply. I know how unnerving the " get it right' issues are for cancer diagnosis. I am amazed at the strength of some patients and your focus on moving forward is a good one. I am trying to focus on eliminating the issues of doctors who do not really have the diagnostic skills or real good mental health..to be practicing medicine. As well as moving forward. My husband chose a primary (family practice) group attached to our medical coverage. The owner, was charged with six counts of sexual abuse/harassment I will give you info from the court notes if you doubt my credibility. He is still in practice with sanctions, and the other doctors on his staff..compromised ethics. During my cancer treatment and diagnosis I was struggling with issues from sexual misconduct and abuse from when I was a young woman. I managed to get through everything and had to handle inappropriate behaviors and comments very often. All aside...and keeping to the subject of cancer treatment and diagnosis...corrupt and unethical discriminatory practices should never be an issue!

One has to believe in the concepts of heaven and hell....I find no consolation in these beliefs. There is so much beauty in this world. I read a tribute to Mother Theresa for her work with the poor. At no time would I diminish helping or caring about anyone but..methinks the rich are probably more difficult!

Kathleen Denny

July 29, 2013 at 9:34 PM

You are so right and this sounds like truly egregious conduct. Nobody should have to deal with this. Unfortunately, while many docs (including family members) are in a state of constant outrage at malpractice suits, I do not find that docs are very good at cleaning their own ranks.

I was diagnosed, DCIS, pre st 1. After needle localization (too tortuous to describe) I had a biopsy. The margins were 'dirty' so the treatment was to be my choice, either mastectomy or wide excision with axillary excision and radiation. I chose the later, and being a 34A and 121 pounds at 5'6-7", I still have chronic pain and shortly after surgery started to have dizziness and equilibrium problems and eventually really severe neck pain. Comedo carcinoma I was told. I quit smoking (40 at the time of my diagnosis) and started walking. I had a miscarriage just before my diagnostic mammogram. I wanted to try and get pregnant again. I walked 10-11-up to 15 miles at a time, I was lifting some weights, etc. My weight was at 131 when I became naturally pregnant after one try. I had been let go from my job along with 400 other employees because of relocation. I used my time to look for new work, exercise..get really healthy. Over the years after my sons birth, I began to drop the pregnancy weight about 154. I was eventually back to between 129 and 131-2 when my real problems started. I had been running and jogging and dancer sizing. I sought help for the sever neck pain and headaches which were getting worse..phys. therapy..made things even worse and epidural injections..thought I was having a stroke and was in the ER. There never has been any diagnosis or was any. I will be 63..the last time I saw a DR. was about 7 years ago. My front clavicles..totally distorted, My weight is up to 145, my headaches are chronic, I have trouble with my arms and hands, speech, coordination, and a real bad leg.
I had so many tests, exams..never anything that did not result in more problems.
My connection was to Drs. that worked for the Catholic Archdiocese. I want to resume my healthy lifestyle....what would you suggest I do?

I was an avid exercise enthusiast before cancer. In the 4+yrs I have been dealing with Stage IV Inflammatory Breast Cancer, exercise has been sporadic. What governs my exercise ability? FATIGUE. With my body being "poisoned" every three weeks to keep cancer at bay, energy levels vary. In the beginning, I would recover from chemotherapy after a week and then slowly get back to exercise. As time went on the recovery periods were longer and the exercise more sporadic. My last chemotherapy, Abraxane, left me severely fatigued for the whole three weeks. I still exercised a little 2-3 days a week, and then would spend the remainder of the day resting. Currently, I am on Kadcyla. I started in March, and now in July, I just beginning to recover some of my former energy. I am able to exercise more consistently, but not at the high levels I enjoyed before cancer. Please remember that the side effects of chemotherapy cause more rapid aging (my mild arthritis is worse) some permanent side effects (lymphodema which restricts weight lifting) and neuropathy that affects my balance. I am a firm believer in the benefits of exercise, but the ravages of chemotherapy are far more onerous and longer lating than your article acknowledges.

I agree with you about the after affects of cancer treatment. I cannot even begin to imagine what chemotherapy must be like after some of the debilitating and painful surgeries one must go through. The last day of my visiting the oncology ward at the hospital where I had radiation treatment I saw a woman there who I saw regularly during treatment..she was undergoing ovarian cancer treatment. She was 38. She was laying in the hall on a gurney..I almost did not recognize her. She had been in the hospital for a chemo round and was there for more radiation....first time I really lost control emotionally. I would like to express my care and support to you....

Thank you for this answer! I have been around so many different patients who expressed such extreme differences in treatments and effects from becoming sterile to having no problems at all with anything.. meds during treatment..none at all...you name it. I found myself digging into JAMA articles, personal testimonies etc. At one visit several years ago I was told I had chronic fatigue and I contradicted the doctor immediately..no specific diagnostic work up. I am always in a quandry. Thanks again! Jill

Yours is a very important observation. Fatigue, which is a side effect of much cancer therapy, is a major problem for many patients. Even if their blood counts are perfect, they are eatting well, they sleep well (all of which are not likely), and even if they exercise, a deep exhaustion can penetrate cancer care. While my article does not address this issue directly, undoubtably for many patients this is the reason they do not exercise.
Thanks for a critical comment,
jcs

And the other problem is just getting started... to keep regularly exercising you need to make it a habit and it takes, what? 3 weeks or so to establish a habit... but you are exhausted, you have a pile up of all the stuff that didn't happen during chemo, a job that eats time, kids clamoring for your attention, laundry, it is 96 degrees outside and 99% humidity but your counts are still low so going to a gym is risky (and that is if you could even afford it anyway) as is walking in a mall... did I mention you are tired and stressed out? Oh yeah and you are fighting with your insurance company, trying to convince your provider not to send you to collection while you sort this out... because if they send you to collection then you can't see your provider until you have paid off the bill, and did I mention tired?
While, in theory, we should all do what we know is good for us, sometimes it takes more than we have in us to get started and keep going long enough to get over those discouraging early weeks where you often feel worse rather than better due to how sore you are, out of shape (which in and of itself is discouraging), and did I mention tired?
Too bad you can't write an Rx for someone to some to your door (paid for by insurance) to drag your sorry rear out for a walk enough times that the exercise starts to be rewarding in and of itself, so that you can get past that hump of starting to do something, anything to start to help you get back in shape.

For a while we had a therapist in our office who gave exercise classes. It was fun and helpful for patients to work out with instructions taylored for their needs. Some physical therapists will do that, but it can be a challenge to find a trainer who is sensitive to the needs of a cancer patient.
jcs

So very true. I, for example, no longer have the muscles that one normally uses to hold up a head or control shoulders. Yet somehow my body devised compensations that worked pretty well for decades. After a relatively recent shoulder surgery I found that most docs and PTs could not imagine how I ever managed to function at the level I reported, much less help me regain it.

James Salwitz, MD

July 29, 2013 at 6:05 PM

Maybe that is part of what exercise provides, the confidence and stamina to find answers when the "professionals" can not.
jcs

Liz

July 28, 2013 at 7:53 PM

Is this 25% a relative or absolute reduction in risk? If it is relative I'd like to translated into absolute risk please. Relative risk is misleading. For example tamoxifen reduces the relative risk of recurrence 50%. Sounds good. But according to my oncotype dx test (I was lucky, I scored a 2) it would only give me an absolute risk reduction of 2-6% (using the 95 confidence interval range, and of course I am then gambling I am in that 95% and not the top 2.5% who are outside that range on the bad end - presuming here a two tailed CI).
Cognitive biases means that phrasing something as 50% vs 2-6% is going to result in different choices. Perhaps physicians need to bone up on cognitive biases so that they can influence behaviors by presenting information in a way that pushes every button to bias patients towards making the choices that make scientific sense (eg triggering the biases when rational decision making isn't going to work with a particular patient)... recognizing that what makes scientific sense and a patient's belief that science works, like gravity works, in all aspects of treatment choices, not just when you want it to, is an iffy proposition at best- OMG do I beat my head against the wall with that on BC lists (and they are far worse than the lymphoma lists in this respect) - hello you choose sentinel node biopsy and lumpectomy plus radiation vs mastectomy because of science but then reject the science that chemo works because of - pick one: the big bad pharma conspiracy, if something is natural/alternative it is better, the profit motive - which is a corollary of big bad pharma - um excuse me and those people selling snake oil, vitamins, natural and alternative treatments don't have a profit motive?...

Meant to add, with a higher oncotype dx score the absolute risk reduction using tamoxifen might be much higher like 30+% which is worlds away in terms of the good it will do from what my particular situation was.

The complicating factor with a high oncotype Dx score may be that the relative risk reduction from tamoxifen may be less (hormonal management is not as effective), thus supporting chemotherapy, in addition to the higher relapse rate.
jcs

Outstanding question and observation. I should blog on that (although, you already have).
Exercise gives a RELATIVE reduction. That means if a patient has a 20% of cancer in their life, it decreases it to 15% or less.
jcs

A separate blog entry would probably be good. My explanation was probably too technical without some additional information for people who already didn't have at least a rudimentary grasp of statistics...

I was an avid runner (marathon, half-marathons, 10k and 5ks), followed a vegan diet and then was hit out of the blue at age 40 with massive seizures in my sleep. Shortly thereafter, I was diagnosed with an inoperable brain tumor - grade 3 anaplastic astrocytoma. No need to go into the prognosis, but needless to say it isn't good. 18 months later I am enjoying a decent quality of life, but know that it is only a matter of time before the disease does what it wills with me. In any event, I try to stay active but find it impossible to maintain the levels of activity I did before I got sick (chemo, radiation and fatigue along with the neurological deterioration just have taken a toll on me). I'm just not what I once was. Regardless, staying active mentally and physically is so critical. I also wanted to say that I really am glad to have stumbled upon your blog. I find your posts deeply human and very inspiring. You are a great person and a fine doctor. - Jason

Thank you for sharing your experience. Keep up the battle. Paradoxically, it is from patients that I find inspiration and see every day the wonder of being human. Glory is not those that climb Everest, it is in those that scale the mountains of each day.
jcs

I finished my treatment in January. Inflammatory breast cancer. I asked all my doctors if there was anything I could do to improve the chance of avoiding or delaying recurrence and metastasis. All told me that science has not been able to find anything for it. Thank you to spend some of your valuable time to communicate with patients. We desperately need.

Certainly my pleasure. I believe that there is significant data that in addition to the aggressive medical therapy that you underwent, that the better you take care of yourself (exercise, low fat diet, rest), the less chance that you will see this disease again. A patient of mine wrote the book, "Cancer Warrior" about her battle with metastatic colon cancer. Despite disease which spread to her liver and pelvis she is alive and healthy years later. I suspect much of this result, in addition to medical treatment, has been her own aggressiveness in how she handled her body. Is this the perfect solution? Of course not. However, it gives patients an edge which just might make the difference. Continue to survive.
jcs

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Sunrinse Rounds provides a doctor’s prospective on the practice of medicine, the process of coping with disease, guidance for improved health, and other general guidance gathered through my life as a medical oncologist.